Request for Applications
New York State Department of Health
Center for Community Health
Division of Family Health
Bureau of Women’s Health
Initiative to Increase Awareness of the Availability of
Emergency Contraception (EC) in New York State
RFA Number #0904090336
RFA Release Date:
July 22, 2009
Questions Due:
August 12, 2009
Applicant Conference On:
August 19, 2009
Deadline for Registration:
August 5, 2009
RFA Updates Posted:
September 14, 2009
Applications Due:
September 28, 2009
DOH Contact Name & Address:
Cheryl L. Veith
Bureau of Women’s Health
Empire State Plaza,
Corning Tower, Room 1805
Albany, New York 12237-0618
Table of Contents
I.
Introduction and Background
A. Background/Intent…………………………………………………………… 1
B. Description of Program……………………………………………………… 2
C. Problems/Issues to be addressed through this RFA…………………… 2
II.
Who May Apply
A. Minimum eligibility requirements…………………………………………… 3
B. Preferred eligibility requirements………………………………………… 3
III.
Project Narrative/Work Plan Outcomes
A. Expectations of the Project………………………………………………… 3
B. Project Narrative……………………………………………………………… 4
C. Expected Outcomes………………………………………………………… 5
IV.
Administrative Requirements
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
V.
Issuing Agency………………………………………………………………
Question and Answer Phase………………………………………………
Applicant Conference………………………………………………………
How to File an Application…………………………………………………
The Department’s Reserved Rights………………………………………
Term of Contract……………………………………………………………
Payment and Reporting Requirements of Grant Awardees……………
Vendor Responsibility Questionnaire……………………………………
General Specifications………………………………………………………
Appendices included in DOH Grant Contracts…………………………
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5
6
7
7
8
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9
9
10
Completing the Application
A. Application Content………………………………………………………… 12
B. Application Format………………………………………………………… 16
C. Review and Award Process……………………………………………… 17
VI.
Attachments…………………………………………………………………… 18
Attachment 1: Standard Grant Contract with Appendices…………………… 19
Attachment 2: Letter of Interest Form………………………………………… 39
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Attachment 3: Application Checklist…………………………………………
Attachment 4: Application Coversheet………………………………………
Attachment 5: Statement of Assurances……………………………………
Attachment 6: Work Plan Form….……………………………………………
Attachment 7: Budget Instructions……………………………………………
Attachment 8: Budget Forms…………………………………………………
Attachment 9: Vendor Responsibility Attestation……………………………
Attachment 10:Vendor Responsibility Questionnaire………………………
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I.
INTRODUCTION AND BACKGROUND
The New York State Department of Health is seeking applicants to develop, implement
and evaluate projects to increase emergency contraception (EC) awareness and access
for women and adolescents at high risk of pregnancy in New York State. This project
will be overseen by the Bureau of Women’s Health within the Division of Family Health,
in the Center for Community Health.
A. Background/Intent
The New York State Department of Health (DOH) has a long history of supporting
women and men in their efforts to control the timing and spacing of births. A planned
pregnancy and birth is much more likely to result in a healthy pregnancy as well as a
healthy mother and baby. To achieve this end, New York State strives on an ongoing
basis to ensure that all New Yorkers of reproductive age have access to comprehensive
family planning and reproductive health care services. An additional and relatively
recent addition to the existing methods of preventing mistimed or unwanted pregnancies
is EC, which can be used in instances where either other contraceptive methods have
failed, or were not used.
The Pregnancy Risk Assessment Monitoring System (PRAMS) survey has consistently
reported that a high percentage of all births are unplanned or mistimed, which indicates
significant barriers to minimizing unplanned pregnancies.
In February of 1997, the Food and Drug Administration (FDA) announced that certain
combinations of estrogen and progestin were safe and effective for use as post coital
emergency contraception. EC prevents pregnancy, but will not terminate or harm an
existing pregnancy. Emergency contraceptive pills taken within 72 hours of unprotected
intercourse reduce the risk of pregnancy by over eighty five percent, from an eight
percent risk after an episode of unprotected intercourse to a one percent risk. The
sooner after intercourse the pills are used, the more effective they are. The most
effective form, known as Plan B®, consists of the hormone levonorgestrel at a higher
dose than that is used in standard birth control pills. The FDA approved Plan B® for
over-the-counter (OTC) sales to women age eighteen and over in August of 2006.
Women younger than eighteen years of age still require a prescription. OTC drug
products require a fiscal order for Medicaid payment. However, to ensure there was no
delay in treatment, a fiscal order is not required to support payment for Plan B® when
provided to women 18 years of age and older. For women under the age of 18, a
prescription will still be required.
Even though EC is now more readily available, women and professionals may still be
either unaware of its availability or misunderstand its use. In 2003, a survey was
conducted by the American College of Obstetricians and Gynecologists (ACOG) of 800
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U.S. women ages eighteen to forty nine. Only six percent reported having ever used
EC. ACOG states that many women are unaware of the existence of EC, lack an
understanding of its use and safety, and do not know how to access EC. In order to
address these issues, the Department is releasing this RFA for outreach and education
on EC.
B. Description of the Program
Under this RFA, the Bureau of Women’s Health will fund up to two applicants to design,
implement and evaluate a statewide initiative (two projects) that will increase awareness
among health care professionals, adolescents and women at high risk for pregnancy, of
the availability of EC in New York State (NYS). In addition to increasing awareness of
the availability of EC, the campaign will promote the need for women to engage in
ongoing reproductive health care services and ongoing methods of family planning and
stress that EC does not protect from sexually transmitted infections (STIs) such as HIV.
It is the intent of the Department that one project will target the downstate region of New
York (New York City, Long Island and the Lower Hudson Valley Region), and one will
target the upstate region of New York (all areas of the state outside of NYC, Long Island
and the Lower Hudson Valley region). Applicants may apply to cover one or both
regions and must submit separate applications for each region they are applying for.
Submission of separate applications for each region is required. If one application to
cover both regions is received, the application will be disqualified.
Up to $500,000 in funding is available in total. Up to two awards at up to $250,000 each
are anticipated. The initial contract period for these awards is expected to be January
1, 2010 through December 31, 2010 with the possibility of renewal for an additional
year. Subsequent funding is contingent upon satisfactory performance, availability of
funding and approval of an annual work plan and budget.
C. Problems/Issues to be addressed through this RFA
The purpose of this RFA is to secure a contractor or contractors who will work with the
Department to reduce unintended pregnancies through a public awareness and
education campaign to advance the understanding of EC as a safe and effective
method of pregnancy prevention. The campaign will be directed to health care
providers, women of reproductive age and professionals serving populations at high risk
for unintended pregnancy and stress the need for ongoing family planning and
reproductive health care services. The Bureau of Women’s Health will fund up to two
applications.
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II.
Who May Apply
A. Minimum Eligibility Requirements
Eligible applicants for this RFA include not-for-profit organizations with demonstrated
capacity and experience in the field of reproductive health services, and health
education and promotion activities.
B. Preferred Eligibility Requirements
Preference will be given to applicants who can demonstrate a strong history of
involvement in the provision of reproductive health care, and outreach and education
activities, who demonstrate extensive experience in working with health care
professionals and communities to strengthen access to services, and who can
demonstrate successful experience designing and implementing multi-media campaigns
on a large scale (e.g., multi-county or statewide basis) targeting populations that have
been historically underserved. Preference will also be given to organizations that
demonstrate successful experience in developing and implementing outreach and
educational campaigns reaching culturally diverse populations.
III.
Project Narrative/ Work Plan Outcomes
A. Expectations of the Project
The Department of Health seeks to award up to two contracts through this RFA to
qualified organizations to develop, implement and evaluate innovative approaches to:
 Educate reproductive health care professionals as well as the health care
community at large about the safety and use of EC;
 Act as a resource for health care providers in design of efforts to educate women
and adolescents about the safety and use of EC, and promote access for
women and adolescents in need of EC;
 Educate non-health care professionals in how to inform women and adolescents
about the availability of EC;
 Identify, develop and pilot test messages and materials to be used to conduct
outreach to women and adolescents who are at high risk for unintended
pregnancy and inform them of the availability and use of EC, as well as
encourage their participation in primary reproductive health care services,
including the use of an ongoing method of effective contraception.
 Develop a plan for optimal distribution of outreach messages and materials to
target population within New York State.
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Applicants may apply to cover one or both regions and must submit a separate
application for each region they are applying for. The project plan and work plan should
fully describe the proposed program, fully summarize the implementation activities and
denote planned outcomes. The goals and objectives for the project should be clearly
stated. Applicants need to utilize the SMART approach in developing their work plan
activities. SMART goals and objectives are defined as Specific, Measurable,
Achievable, Realistic and Timely. Each objective should be stated in measurable terms,
specifying the implementation activities, deliverables, time frame, person(s) responsible
and evaluation measure. Each objective described in the work plan should explain the
kind and quantity of work and activities that will be implemented to accomplish the
proposed objective and expected outcomes.
B. Project Narrative
Awareness and outreach campaigns are highly effective ways to publicize the
availability and importance of reproductive health care services. The purpose of this
funding is to increase awareness among both professionals and women of reproductive
age about the utilization of EC as an effective means to prevent unintended
pregnancies when contraceptive methods have failed or have not been used. The
public awareness campaign will increase awareness of the use and availability of EC for
adolescents and women at high risk of pregnancy. The pilot outreach and education
campaign targeted at health care and other professionals will increase the number of
opportunities that exist for health care and other professionals (e.g., social workers,
counselors, etc.) to promote awareness of EC to at-risk populations. Education will
enable health care professionals to integrate education, counseling and provision of EC
into their routine clinical practice.
This RFA focuses on two major components to increase awareness of EC to reduce
access barriers for women and adolescents of reproductive age. Under this
procurement, applicants need to describe how they will address the following
components:
1. The first component targets the health care delivery system by supporting health
care providers and organizations in the integration of EC information and
education into current services. The literature suggests that such community
partnerships are highly effective in reaching women of reproductive age.
Community partners are health care providers such as physicians (obstetricians
and gynecologists, pediatricians, family practice physicians, etc.) midwives,
physician assistants, etc., as well as agencies and organizations that have
access to and are trusted by adolescents and women, who provide information,
advocacy, social support and health care services. Health care professionals,
social workers and others who work directly with this target population possess
the skills to engage and counsel adolescents and women. Often because such
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professionals have relationships with high risk youth and vulnerable women, they
are able to provide medically accurate information and education about EC, and
identify and reduce barriers to access. They can also encourage and assist their
clients to seek ongoing reproductive health care services. The successful
applicant will design a program identifying best practices and provide technical
assistance that targets these professionals/community partners.
2. The second component is a pilot educational and media campaign which targets
females of reproductive age, the consumers of EC, regarding the safety, efficacy
and availability of EC. The messages to consumers need to include information
on the availability, safety and effectiveness of EC, dispel myths regarding the use
and safety of EC, and must stress that EC does not protect against STIs and
does not preclude the need for ongoing family planning and reproductive health
care services. The pilot educational and media campaign should consist of
messages and materials which have been focus-tested, along with a researchbased plan to outreach to the intended audience using appropriate modalities
such as the internet, text messages, and social networking sites such as Face
Book, You Tube and MySpace.
The application should include innovative materials and approaches to target
adolescents and women. The application should also include strategies
designed to best meet the identified target population. Methods to reach
culturally diverse communities need to also be described.
C. Expected Outcomes
Funded projects will be expected to produce measurable increases in use of EC, and be
able to demonstrate the impact of efforts on various populations of reproductive aged
women. These efforts should result in a decrease in unplanned pregnancies, but
interim measures, including increased usage of EC, increased knowledge of the efficacy
and safety of EC among professionals and related health care workers, and among
reproductive aged women, may be used as outcome measures if the impact is expected
beyond the period of the grant.
IV.
Administrative Requirements
A.
Issuing Agency
This Request for Applications (RFA) is issued by the NYS Department of Health, Center
for Community Health, Division of Family Health, Bureau of Women’s Health. The
department is responsible for the requirements specified herein and for the evaluation of
all applications.
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B.
Question and Answer Phase:
All substantive questions need to be submitted in writing to:
Cheryl L. Veith
Bureau of Women’s Health
Empire State Plaza, Corning Tower Building
Room 1805, Albany, New York 12237-0657
[email protected]
To the degree possible, each inquiry should cite the RFA section and paragraph to
which it refers. Written questions will be accepted until the date posted on the cover of
this RFA.
Questions of a technical nature can be addressed in writing or via telephone by calling
Cheryl L. Veith, [email protected], (518) 474-3368. Questions are of a
technical nature if they are limited to how to prepare your application (e.g.,
formatting) rather than relating to the substance of the application.
Prospective applicants should note that all clarification and exceptions, including those
relating to the terms and conditions of the contract, are to be raised prior to the
submission of an application.
This RFA has been posted on the Department of Health's public website at:
http://www.nyhealth.gov/funding/. Questions and answers, as well as any updates
and/or modifications, will also be posted on the Department of Health's website. All
such updates will be posted by the date identified on the cover sheet of this RFA.
If prospective applicants would like to receive notification when updates/modifications
are posted (including responses to written questions, responses to questions raised at
the applicant conference, official applicant conference minutes), please complete and
submit a letter of interest (see attachment 2).
Submission of a letter of interest is not a requirement for submitting an application.
C.
Applicant Conference
An Applicant Conference will be held for this project. This conference will be held
via teleconference on the date and time posted on the cover sheet of this RFA. The
Department requests that potential applicants register for this conference by completing
the non-mandatory letter of interest form (attachment 2) to insure that adequate
accommodations be made for the number of prospective attendees. A maximum
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number of 2 telephone lines will be allotted to each prospective applicant in order to
participate in the applicant conference. Failure to attend the Applicant conference will
not preclude the submission of an application. The deadline for reservations for the
applicant conference is posted on the cover page of this RFA.
D.
How to file an application
Applications must be received at the following address by the date and time posted on
the cover sheet of this RFA. Late applications will not be accepted. *
Cheryl L. Veith
Bureau of Women’s Health
Empire State Plaza, Corning Tower Building
Room 1805, Albany, New York 12237-0618
Applicants may apply to cover one or both regions and must submit a separate
application for each region they are applying for. Applicants shall submit two (2)
original, unbound signed applications and six (6) bound copies including attachments.
The application should be printed on 8.5” x 11” standard letter-size paper. Pages
should be consecutively numbered. Application packages should be clearly labeled
with the name and number of the RFA as listed on the cover of this RFA document.
Applications will not be accepted via fax or e-mail.
*It is the applicant’s responsibility to see that applications are delivered to
the address above by the date and time specified. Late applications due
to a documentable delay by the carrier may be considered at the
Department of Health's discretion.
E.
THE DEPARTMENT OF HEALTH RESERVES THE RIGHT TO
1. Reject any or all applications received in response to this RFA.
2. Award more than one contract resulting from this RFA.
3. Waive or modify minor irregularities in applications received after prior
notification to the applicant.
4. Adjust or correct cost figures with the concurrence of the applicant if errors
exist and can be documented to the satisfaction of DOH and the State
Comptroller.
5. Negotiate with applicants responding to this RFA within the requirements to
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serve the best interests of the State.
6. Eliminate mandatory requirements unmet by all applicants.
7. If the Department of Health is unsuccessful in negotiating a contract with the
selected applicant within an acceptable time frame, the Department of Health
may begin contract negotiations with the next qualified applicant(s) in order to
serve and realize the best interests of the State.
8. The Department of Health reserves the right to award grants based on
geographic or regional considerations to serve the best interests of the state.
F.
Term of Contract
Any contract resulting from this RFA will be effective only upon approval by the New
York State Office of the Comptroller.
It is expected that contracts resulting from this RFA will have the following time period:
January 1, 2010 through December 31, 2010. Subsequent funding for one additional
year is contingent upon satisfactory performance, availability of funding and approval of
an annual Work plan and Budget.
G.
Payment & Reporting Requirements of Grant Awardees
1. The State (NYS Department of Health) may, at its discretion, make an
advance payment to not-for-profit grant contractors in an amount not to
exceed 25% percent.
2. The grant contractor will be required to submit QUARTERLY invoices and
required reports of expenditures to the State's designated payment office:
Division of Family Health-Fiscal Unit
NYS Department of Health
Corning Tower Building-Room 878
Albany, NY 12237-0657
Payment of such invoices by the State (NYS Department of Health) shall be
made in accordance with Article XI-A of the New York State Finance Law.
Payment terms will be: Payments will be made on a quarterly basis
contingent upon receipt of all required reports.
3. The grant contractor will be required to submit the following periodic reports:
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The State shall supply the contractor with standard vouchers to
submit for payment. A Budget Statement and Report of
Expenditures, as well as a written quarterly report of program
objectives, will be required for payment. Payments will be made for
reimbursable expenses only.
All payment and reporting requirements will be detailed in Appendix C of the final
grant contract.
H.
Vendor Responsibility Questionnaire
New York State Procurement Law requires that state agencies award contracts
only to responsible vendors. Vendors are invited to file the required Vendor
Responsibility Questionnaire online via the New York State VendRep System or
may choose to complete and submit a paper questionnaire. To enroll in and use
the New York State VendRep System, see the VendRep System Instructions
available at www.osc.state.ny.us/vendrep or go directly to the VendRep system
online at https://portal.osc.state.ny.us. For direct VendRep System user
assistance, the OSC Help Desk may be reached at 866-370-4672 or 518-4084672 or by email at [email protected]. Vendors opting to file a paper
questionnaire can obtain the appropriate questionnaire from the VendRep
website www.osc.state.ny.us/vendrep or may contact the Department of Health
or the Office of the State Comptroller for a copy of the paper form. Applicants
must also complete and submit the Vendor Responsibility Attestation
(Attachment 9).
I.
General Specifications
1.
By signing the "Application Form" each applicant attests to its express
authority to sign on behalf of the applicant.
2.
Contractor will possess, at no cost to the State, all qualifications, licenses
and permits to engage in the required business as may be required within
the jurisdiction where the work specified is to be performed. Workers to
be employed in the performance of this contract will possess the
qualifications, training, licenses and permits as may be required within
such jurisdiction.
3.
Submission of an application indicates the applicant's acceptance of all
conditions and terms contained in this RFA, including the terms and
conditions of the contract. Any exceptions allowed by the Department
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during the Question and Answer Phase (Section IV.B.) must be clearly
noted in a cover letter attached to the application.
J.
4.
An applicant may be disqualified from receiving awards if such applicant
or any subsidiary, affiliate, partner, officer, agent or principal thereof, or
anyone in its employ, has previously failed to perform satisfactorily in
connection with public bidding or contracts.
5.
Provisions Upon Default
a.
The services to be performed by the Applicant shall be at all times
subject to the direction and control of the Department as to all
matters arising in connection with or relating to the contract
resulting from this RFA.
b.
In the event that the Applicant, through any cause, fails to perform
any of the terms, covenants or promises of any contract resulting
from this RFA, the Department acting for and on behalf of the State,
shall thereupon have the right to terminate the contract by giving
notice in writing of the fact and date of such termination to the
Applicant.
c.
If, in the judgement of the Department of Health, the Applicant acts
in such a way which is likely to or does impair or prejudice the
interests of the State, the Department acting on behalf of the State,
shall thereupon have the right to terminate any contract resulting
from this RFA by giving notice in writing of the fact and date of such
termination to the Contractor. In such case the Contractor shall
receive equitable compensation for such services as shall, in the
judgement of the State Comptroller, have been satisfactorily
performed by the Contractor up to the date of the termination of this
agreement, which such compensation shall not exceed the total
cost incurred for the work which the Contractor was engaged in at
the time of such termination, subject to audit by the State
Comptroller.
Appendices
The following will be incorporated as appendices into any contract(s) resulting
from this Request for Application.
APPENDIX A -
Standard Clauses for All New York State Contracts
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APPENDIX A-1
Agency Specific Clauses
APPENDIX A-2
Program Specific Clauses
APPENDIX B -
Budget
APPENDIX C -
Payment and Reporting Schedule
APPENDIX D -
Workplan
APPENDIX E - Unless the CONTRACTOR is a political sub-division of
New York State, the CONTRACTOR shall provide proof, completed by the
CONTRACTOR's insurance carrier and/or the Workers' Compensation
Board, of coverage for:
Workers' Compensation, for which one of the following is
incorporated into this contract as Appendix E-1:
•
CE-200 - Certificate of Attestation For New York Entities
With No Employees And Certain Out Of State Entities, That
New York State Workers' Compensation And/Or Disability
Benefits Insurance Coverage is Not Required; OR
•
C-105.2 -- Certificate of Workers' Compensation Insurance.
PLEASE NOTE: The State Insurance Fund provides its own
version of this form, the U-26.3; OR
•
SI-12 -- Certificate of Workers' Compensation SelfInsurance, OR GSI-105.2 -- Certificate of Participation in
Workers' Compensation Group Self-Insurance
Disability Benefits coverage, for which one of the following is
incorporated into this contract as Appendix E-2:
•
CE-200 - Certificate of Attestation For New York Entities
With No Employees And Certain Out Of State Entities, That
New York State Workers' Compensation and/or Disability
Benefits Insurance Coverage is Not Required; OR
•
DB-120.1 -- Certificate of Disability Benefits Insurance OR
•
DB-155 -- Certificate of Disability Benefits Self-Insurance
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NOTE: Do not include the Workers’ Compensation and
Disability Benefits forms with your application.
These documents will be requested as a part of the contracting
process should you receive an award.
V.
Completing the Application
A.
Application Content
Applicants may apply to cover one or both regions and must submit a separate
application for each region for which they are applying. Applications should not exceed
25 single-spaced typed pages (not including the cover page, work plan, budget,
budget justification and attachments: letters of support, letters of cooperation or
memoranda of understanding, organization chart), using a pitch font not smaller than
twelve (12) with one (1) inch margins on all sides.
Submission of an application indicates the applicant’s acceptance of all conditions and
terms contained in this RFA. All applicants must submit all required elements listed
below including the Application Cover Sheet (Attachment 4) and the Signed
Statement of Assurances (Attachment 5).
1. Cover Page and Assurances
Cover Page (The cover page will not count toward the page limit)
A form is provided in Attachment 4 that will serve as the application cover page
and the application bid form. The form needs to be signed off by an official in the
applicant organization having the authority to agree to and ensure deliverables in
the application (e.g., the Chief Executive Officer or the Chairperson of the Board
of Directors). The cover page should also include the name of the person who
should be contacted by those seeking information about the application, the full
mailing address, telephone number, fax number and e-mail address. Indicate on
the cover page the region to be served. Applications submitted without an
properly completed cover page will be disqualified.
Statement of Assurances (This page will not count toward the page limit)
Complete and sign the attached Statement of Assurances (Attachment 5). The
form needs to be signed by the chief official (e.g., the Chief Executive Officer or
the Chairperson of the Board of Directors) of the applicant agency. Applications
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submitted without a properly completed Statement of Assurances will be
disqualified.
2. Project Summary
(maximum 2 pages)
5 points
Provide a summary of the project, which describes the intent of the project, the
population(s) to be served, the geographic region(s) and the scope of activities
and anticipated outcomes.
3. Statement of Need (maximum 3 pages)
15 points
Two geographic regions have been identified to ensure statewide coverage. The
applicant will describe the need for outreach and education services in the
selected region to increase awareness of EC to reduce barriers to access for
women and adolescents of reproductive age within that region. Please note:
Applicants must submit separate applications for each region proposed to be
served.
The applicant will describe the evidence base for needs that are identified.
Examples of such evidence include community needs assessment, health care
provider surveys, focus group reports, surveillance data, and scientific literature.
Identified barriers should be described as well.
The applicant will:




Describe major characteristics of the region regarding reproductive health
status indicators.
Describe major issues related to the awareness and use of EC
experienced by health care providers and communities.
Describe the learning needs of health care providers within the region
related to the provision of comprehensive reproductive healthcare and EC.
Describe current needs and barriers regarding EC experienced by
providers and communities.
4. Organizational Capacity (maximum 3 pages)
15 points
Provide a description of your agency, its mission, goals and current services.
Provide a thorough description of the agency’s experience and capacity to
provide services funded by grant dollars to the target populations.
Applicants should summarize resources that will enable them to provide expert,
comprehensive reproductive health care information to providers and
communities across New York State. Applicants should describe their past
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experience with conducting innovative outreach initiatives and developing and
disseminating educational materials to the target audiences for this initiative:
health care providers, community agencies serving women of reproductive age
and consumers of EC.
The applicant will describe any relevant experience their agency and each
proposed subcontractor possesses in regard to:



Addressing unintended pregnancy and/or working with populations at risk
of unintended pregnancy.
Working in the field of reproductive health, health education and/or
professional development.
Working with adolescents and women of reproductive age, including
culturally diverse populations and others from the target area that may be
hard to engage.
5. Project Narrative (maximum 15 pages)
15 points
The project narrative is a description of the proposed project. The applicant will
define the goals of the project while providing specific, measurable, time-period
objectives to accomplish the goals in the context of a one-year project. The
applicant will describe how the project will address the issues described in the
statement of need and the rationale for the approach.
Explain how the proposed activities address the following required components:
A.
The campaign will target the health care delivery system by
integrating EC information into services provided by health care
providers and organizations. The applicant will design and
implement an innovative campaign that targets
professionals/community partners.



Describe how the campaign will conduct outreach and provide
education about the use and safety of EC to health care
providers in the targeted region.
Describe how the campaign will conduct outreach and provide
education promoting ongoing reproductive health care and
contraceptive use to health care providers in the targeted
region.
Describe resources and technical assistance to be available to
health care providers.
B. The pilot public education and media campaign will target consumers
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of EC, i.e., females of reproductive age, regarding the safety, efficacy
and availability of EC. The applicant will design and implement an
innovative campaign for this audience.


Describe how the campaign will develop and test materials to
conduct outreach and provide education to consumers in the
targeted region regarding the use and safety and availability of
EC.
Describe other proposed activities related to outreach and
education for consumers.
Document support (letters of intent, memoranda of agreement, etc.) by partner
agencies (local health centers/clinics, community-based organizations, etc.)
including, if applicable, expressed intention to provide collaboration.
6. Work Plan (use Attachment 6)
The work plan will not count toward the page limit.
15 points
Applicants will need to complete the work plan for achieving the project’s one
year objectives. The applicants will need to utilize the SMART approach in
developing their work plan activities. SMART goals and objectives are defined
as Specific, Measurable, Achievable, Realistic and Timely. Each objective
should be stated in measurable terms, specifying the implementation activities,
deliverables, time frame, person(s) responsible and evaluation measure. Each
objective described in the work plan should explain the kind and quantity of work
and activities that will be implemented to accomplish the proposed objective and
expected outcomes.
7. Evaluation (maximum 2 pages)
15 points
Plans for monitoring progress on objectives should be described in detail. For
each activity, describe outcome indicators and how they will be measured.
8. Budget and Budget Justification (use Attachments 7 and 8) 20 points
The budget pages and justification will not count toward the page limit.
Complete the attached budget forms, (Attachment 8) in their entirety.
Applicants need to submit a 12-month budget, assuming an January 1, 2010,
start date. The budget narrative should explain the one year budget. All costs
need to be related to the provision of services as described in this RFA. The
justification for each cost should be submitted in a narrative form. The budget
needs to be reasonable and cost effective and include only reimbursable items.
For all existing staff, the budget justification need to delineate how the
15
percentage of time devoted to this initiative has been determined and time
budgeted need to be consistent with job descriptions and activities described in
the work plan.
Applicants should indicate in-kind support for the project and projected sources
of funding. Complete job descriptions which indicate the title, function, specific
responsibilities and required qualifications of all persons to be supported by
project funds need to be included in the application.
Ineligible budget items will be removed from the budget before the budget is
scored. The budget amount requested will be reduced to reflect the removal of
the ineligible items.
Administrative costs need to be lined out showing detail (vs. lump sum) and will
be limited to a maximum of 10 percent of the amount being requested from New
York State. Expenditures will not be allowed for the purchase of major pieces of
depreciable equipment or remodeling or modification of structure (although
limited computer/printing equipment may be considered). Indirect costs as a
percentage lump sum will not be allowed. Budgets received using a percentage
lump sum will be reduced by the percentage lump sum requested.
B.
Application Format
ALL APPLICATIONS SHOULD CONFORM TO THE FORMAT PRESCRIBED BELOW.
POINTS WILL BE DEDUCTED FROM APPLICATIONS WHICH DEVIATE FROM THE
PRESCRIBED FORMAT.
Applications should not exceed 25, single-spaced typed pages (not including the
cover page, budget and attachments), using a pitch font not smaller than twelve (12).
The value assigned to each section is an indication of the relative weight that will be
given when scoring your application.
A maximum of 5 points may be deducted for applications failing to follow the prescribed
format. Applicants who do not meet eligibility requirements or fail to submit a cover
sheet and/or Program Summary may be removed from consideration.
Application Components
Page Limits
Max. Score
1.
2.
3.
4.
5.
N/A
2 pages
3 pages
3 pages
15 pages
No score
5
15
15
15
Cover Page/Assurances
Project Summary
Statement of Need
Organizational Capacity
Project Narrative
16
6.
7.
8.
9.
Work plan
Evaluation
Budget and Budget Justification
Letters of agreement
Total application
C.
No page limit
Not to exceed 2 pages
No page limit
No page limit
15
15
20
No score
Not to exceed 25 pages 100
Review & Award Process
Applications meeting the guidelines set forth above will be reviewed and evaluated
competitively by the NYSDOH, Center for Community Health, Division of Family Health.
The Department reserves the right to obtain reviewers outside the sponsoring bureau,
the Bureau of Women’s Health.
Two Initiatives to Increase Awareness of the Availability of Emergency Contraception
(EC) in New York State will be funded for up to $250,000 each per year, for a total of
$500,000. One applicant may apply for and be awarded funding to implement both
projects.
All applications will be scored using a standardized tool. Each proposal will be reviewed
by a minimum of three reviewers, whose scores will be averaged to arrive at a final
score for each application. Scores will be ranked from highest to lowest, with higher
scores being most desirable. Applicants with average scores below 60 will not be
considered for funding. The applicant with the highest score in the respective region
(Downstate region and Upstate region) will receive the award to provide services in that
region.
Following the award of grants from this RFA, applicants may request a debriefing from
the NYS DOH, Center for Community Health, Division of Family Health, Bureau of
Women’s Health for three months following the award(s) announcement. This
debriefing will be limited to the positive and negative aspects of the subject application.
17
VI.
Attachments
Attachment 1: Standard Grant Contract with Appendices
Attachment 2: Letter of Interest Form
Attachment 3: Application Checklist
Attachment 4: Application Coversheet
Attachment 5: Statement of Assurances
Attachment 6: Work Plan Form
Attachment 7: Budget Instructions
Attachment 8: Budget Forms
Attachment 9: Vendor Responsibility Attestation
Attachment 10:Vendor Responsibility Questionnaire
18
Attachment 1
GRANT CONTRACT
STATE AGENCY (Name and Address):
_______________________________________
CONTRACTOR (Name and Address):
_______________________________________
FEDERAL TAX IDENTIFICATION NUMBER:
MUNICIPALITY NO. (if applicable):
CHARITIES REGISTRATION NUMBER:
__ __ - __ __ - __ __
or
( ) EXEMPT:
(If EXEMPT, indicate basis for exemption):
_______________________________________
CONTRACTOR HAS( ) HAS NOT( ) TIMELY
FILED WITH THE ATTORNEY GENERAL’S
CHARITIES BUREAU ALL REQUIRED PERIODIC
OR ANNUAL WRITTEN REPORTS.
______________________________________
CONTRACTOR IS( ) IS NOT( ) A
SECTARIAN ENTITY
CONTRACTOR IS( ) IS NOT( ) A
NOT-FOR-PROFIT ORGANIZATION
.
.
.
.
.
.
.
.
.
NYS COMPTROLLER’S NUMBER: ______
.
.
.
.
.
.
.
.
.
.
FROM:
ORIGINATING AGENCY CODE:
___________________________________
TYPE OF PROGRAM(S)
___________________________________
INITIAL CONTRACT PERIOD
TO:
FUNDING AMOUNT FOR INITIAL PERIOD:
___________________________________
MULTI-YEAR TERM (if applicable):
FROM:
TO:
APPENDICES ATTACHED AND PART OF THIS AGREEMENT
_____
APPENDIX A
_____
_____
_____
_____
_____
APPENDIX A-1
APPENDIX B
APPENDIX C
APPENDIX D
APPENDIX X
Standard clauses as required by the Attorney General for all State
contracts.
Agency-Specific Clauses (Rev 10/08)
Budget
Payment and Reporting Schedule
Program Workplan
Modification Agreement Form (to accompany modified appendices
for changes in term or consideration on an existing period or for
renewal periods)
OTHER APPENDICES
_____
_____
_____
_____
APPENDIX A-2
APPENDIX E-1
APPENDIX E-2
APPENDIX H
_____
_____
APPENDIX ___
APPENDIX ___
Program-Specific Clauses
Proof of Workers’ Compensation Coverage
Proof of Disability Insurance Coverage
Federal Health Insurance Portability and Accountability Act
Business Associate Agreement
__________________________________________________
__________________________________________________
10/08
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates
below their signatures.
_______________________________________
.
___________________________________
.
Contract No. ________________________
_______________________________________
.
___________________________________
CONTRACTOR
.
STATE AGENCY
_______________________________________
.
___________________________________
By: ____________________________________
.
By: ________________________________
(Print Name)
(Print Name)
_______________________________________
.
___________________________________
Title: ___________________________________
.
Title: _______________________________
Date: ___________________________________
.
Date: ______________________________
.
.
.
.
.
.
State Agency Certification:
“In addition to the acceptance of this contract,
I also certify that original copies of this signature
page will be attached to all other exact copies of
this contract.”
_______________________________________ .
___________________________________
STATE OF NEW YORK
County of
)
)
)
SS:
On the
day of
in the year ______ before me, the undersigned, personally appeared
___________________________________, personally known to me or proved to me on the basis of
satisfactory evidence to be the individual(s) whose name(s) is(are) subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their/ capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the
individual(s) acted, executed the instrument.
_____________________________________
(Signature and office of the individual taking acknowledgement)
ATTORNEY GENERAL’S SIGNATURE
.
STATE COMPTROLLER’S SIGNATURE
_______________________________________ .
___________________________________
Title: ___________________________________
.
Title: _______________________________
Date: ___________________________________
.
Date: ______________________________
10/08
STATE OF NEW YORK
AGREEMENT
This AGREEMENT is hereby made by and between the State of New York agency (STATE) and
the public or private agency (CONTRACTOR) identified on the face page hereof.
WITNESSETH:
WHEREAS, the STATE has the authority to regulate and provide funding for the
establishment and operation of program services and desires to contract with skilled parties
possessing the necessary resources to provide such services; and
WHEREAS, the CONTRACTOR is ready, willing and able to provide such program services
and possesses or can make available all necessary qualified personnel, licenses, facilities and
expertise to perform or have performed the services required pursuant to the terms of this
AGREEMENT;
NOW THEREFORE, in consideration of the promises, responsibilities and convenants
herein, the STATE and the CONTRACTOR agree as follows:
I.
Conditions of Agreement
A.
This AGREEMENT may consist of successive periods (PERIOD), as specified within
the AGREEMENT or within a subsequent Modification Agreement(s) (Appendix X).
Each additional or superseding PERIOD shall be on the forms specified by the
particular State agency, and shall be incorporated into this AGREEMENT.
B.
Funding for the first PERIOD shall not exceed the funding amount specified on the
face page hereof. Funding for each subsequent PERIOD, if any, shall not exceed
the amount specified in the appropriate appendix for that PERIOD.
C.
This AGREEMENT incorporates the face pages attached and all of the marked
appendices identified on the face page hereof.
D.
For each succeeding PERIOD of this AGREEMENT, the parties shall prepare new
appendices, to the extent that any require modification, and a Modification
Agreement (the attached Appendix X is the blank form to be used). Any terms of this
AGREEMENT not modified shall remain in effect for each PERIOD of the
AGREEMENT.
To modify the AGREEMENT within an existing PERIOD, the parties shall revise or
complete the appropriate appendix form(s).
Any change in the amount of
consideration to be paid, or change in the term, is subject to the approval of the
Office of the State Comptroller. Any other modifications shall be processed in
accordance with agency guidelines as stated in Appendix A-1.
E.
The CONTRACTOR shall perform all services to the satisfaction of the STATE. The
CONTRACTOR shall provide services and meet the program objectives summarized
in the Program Workplan (Appendix D) in accordance with: provisions of the
AGREEMENT; relevant laws, rules and regulations, administrative and fiscal
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guidelines; and where applicable, operating certificates for facilities or licenses for an
activity or program.
II.
III.
F.
If the CONTRACTOR enters into subcontracts for the performance of work pursuant
to this AGREEMENT, the CONTRACTOR shall take full responsibility for the acts
and omissions of its subcontractors. Nothing in the subcontract shall impair the rights
of the STATE under this AGREEMENT. No contractual relationship shall be deemed
to exist between the subcontractor and the STATE.
G.
Appendix A (Standard Clauses as required by the Attorney General for all State
contracts) takes precedence over all other parts of the AGREEMENT.
Payment and Reporting
A.
The CONTRACTOR, to be eligible for payment, shall submit to the STATE’s
designated payment office (identified in Appendix C) any appropriate documentation
as required by the Payment and Reporting Schedule (Appendix C) and by agency
fiscal guidelines, in a manner acceptable to the STATE.
B.
The STATE shall make payments and any reconciliations in accordance with the
Payment and Reporting Schedule (Appendix C). The STATE shall pay the
CONTRACTOR, in consideration of contract services for a given PERIOD, a sum not
to exceed the amount noted on the face page hereof or in the respective Appendix
designating the payment amount for that given PERIOD. This sum shall not
duplicate reimbursement from other sources for CONTRACTOR costs and services
provided pursuant to this AGREEMENT.
C.
The CONTRACTOR shall meet the audit requirements specified by the STATE.
Terminations
A.
This AGREEMENT may be terminated at any time upon mutual written consent of the
STATE and the CONTRACTOR.
B.
The STATE may terminate the AGREEMENT immediately, upon written notice of
termination to the CONTRACTOR, if the CONTRACTOR fails to comply with the
terms and conditions of this AGREEMENT and/or with any laws, rules and
regulations, policies or procedures affecting this AGREEMENT.
C.
The STATE may also terminate this AGREEMENT for any reason in accordance with
provisions set forth in Appendix A-1.
D.
Written notice of termination, where required, shall be sent by personal messenger
service or by certified mail, return receipt requested. The termination shall be
effective in accordance with the terms of the notice.
E.
Upon receipt of notice of termination, the CONTRACTOR agrees to cancel, prior to
the effective date of any prospective termination, as many outstanding obligations as
possible, and agrees not to incur any new obligations after receipt of the notice
without approval by the STATE.
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F.
IV.
V.
The STATE shall be responsible for payment on claims pursuant to services provided
and costs incurred pursuant to terms of the AGREEMENT. In no event shall the
STATE be liable for expenses and obligations arising from the program(s) in this
AGREEMENT after the termination date.
Indemnification
A.
The CONTRACTOR shall be solely responsible and answerable in damages for any
and all accidents and/or injuries to persons (including death) or property arising out of
or related to the services to be rendered by the CONTRACTOR or its subcontractors
pursuant to this AGREEMENT. The CONTRACTOR shall indemnify and hold
harmless the STATE and its officers and employees from claims, suits, actions,
damages and costs of every nature arising out of the provision of services pursuant
to this AGREEMENT.
B.
The CONTRACTOR is an independent contractor and may neither hold itself out nor
claim to be an officer, employee or subdivision of the STATE nor make any claims,
demand or application to or for any right based upon any different status.
Property
Any equipment, furniture, supplies or other property purchased pursuant to this
AGREEMENT is deemed to be the property of the STATE except as may otherwise be
governed by Federal or State laws, rules and regulations, or as stated in Appendix A-2.
VI.
Safeguards for Services and Confidentiality
A.
Services performed pursuant to this AGREEMENT are secular in nature and shall be
performed in a manner that does not discriminate on the basis of religious belief, or
promote or discourage adherence to religion in general or particular religious beliefs.
B.
Funds provided pursuant to this AGREEMENT shall not be used for any partisan
political activity, or for activities that may influence legislation or the election or defeat
of any candidate for public office.
C.
Information relating to individuals who may receive services pursuant to this
AGREEMENT shall be maintained and used only for the purposes intended under
the contract and in conformity with applicable provisions of laws and regulations, or
specified in Appendix A-1.
10/08
APPENDIX A-1
(REV 10/08)
AGENCY SPECIFIC CLAUSES FOR ALL
DEPARTMENT OF HEALTH CONTRACTS
1. If the CONTRACTOR is a charitable organization required to be registered with the New York State
Attorney General pursuant to Article 7-A of the New York State Executive Law, the CONTRACTOR shall
furnish to the STATE such proof of registration (a copy of Receipt form) at the time of the execution of
this AGREEMENT. The annual report form 497 is not required. If the CONTRACTOR is a business
corporation or not-for-profit corporation, the CONTRACTOR shall also furnish a copy of its Certificate of
Incorporation, as filed with the New York Department of State, to the Department of Health at the time of
the execution of this AGREEMENT.
2. The CONTRACTOR certifies that all revenue earned during the budget period as a result of services
and related activities performed pursuant to this contract shall be used either to expand those program
services funded by this AGREEMENT or to offset expenditures submitted to the STATE for
reimbursement.
3. Administrative Rules and Audits:
a.
If this contract is funded in whole or in part from federal funds, the CONTRACTOR shall
comply with the following federal grant requirements regarding administration and allowable
costs.
i.
For a local or Indian tribal government, use the principles in the common rule,
"Uniform Administrative Requirements for Grants and Cooperative Agreements to
State and Local Governments," and Office of Management and Budget (OMB)
Circular A-87, "Cost Principles for State, Local and Indian Tribal Governments".
ii. For a nonprofit organization other than
♦ an institution of higher education,
♦ a hospital, or
♦ an organization named in OMB Circular A-122, “Cost Principles for Non-profit
Organizations”, as not subject to that circular,
use the principles in OMB Circular A-110, "Uniform Administrative Requirements for
Grants and Agreements with Institutions of Higher Education, Hospitals and Other
Non-profit Organizations," and OMB Circular A-122.
iii. For an Educational Institution, use the principles in OMB Circular
A-110 and OMB Circular A-21, "Cost Principles for Educational Institutions".
iv. For a hospital, use the principles in OMB Circular A-110, Department of Health and
Human Services, 45 CFR 74, Appendix E, "Principles for Determining Costs
Applicable to Research and Development Under Grants and Contracts with
Hospitals" and, if not covered for audit purposes by OMB Circular A-133, “Audits of
States Local Governments and Non-profit Organizations”, then subject to program
specific audit requirements following Government Auditing Standards for financial
audits.
b.
If this contract is funded entirely from STATE funds, and if there are no specific
administration and allowable costs requirements applicable, CONTRACTOR shall adhere to
the applicable principles in “a” above.
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c.
The CONTRACTOR shall comply with the following grant requirements regarding audits.
i.
If the contract is funded from federal funds, and the CONTRACTOR spends more
than $500,000 in federal funds in their fiscal year, an audit report must be
submitted in accordance with OMB Circular A-133.
ii. If this contract is funded from other than federal funds or if the contract is funded from
a combination of STATE and federal funds but federal funds are less than $500,000,
and if the CONTRACTOR receives $300,000 or more in total annual payments from
the STATE, the CONTRACTOR shall submit to the STATE after the end of the
CONTRACTOR's fiscal year an audit report. The audit report shall be submitted to
the STATE within thirty days after its completion but no later than nine months after
the end of the audit period. The audit report shall summarize the business and
financial transactions of the CONTRACTOR. The report shall be prepared and
certified by an independent accounting firm or other accounting entity, which is
demonstrably independent of the administration of the program being audited. Audits
performed of the CONTRACTOR's records shall be conducted in accordance with
Government Auditing Standards issued by the Comptroller General of the United
States covering financial audits. This audit requirement may be met through entitywide audits, coincident with the CONTRACTOR's fiscal year, as described in OMB
Circular A-133. Reports, disclosures, comments and opinions required under these
publications should be so noted in the audit report.
d.
For audit reports due on or after April 1, 2003, that are not received by the dates due, the
following steps shall be taken:
i.
If the audit report is one or more days late, voucher payments shall be held until a
compliant audit report is received.
ii. If the audit report is 91 or more days late, the STATE shall recover payments for all
STATE funded contracts for periods for which compliant audit reports are not
received.
iii. If the audit report is 180 days or more late, the STATE shall terminate all active
contracts, prohibit renewal of those contracts and prohibit the execution of future
contracts until all outstanding compliant audit reports have been submitted.
4. The CONTRACTOR shall accept responsibility for compensating the STATE for any
exceptions which are revealed on an audit and sustained after completion of the normal
audit procedure.
5. FEDERAL CERTIFICATIONS: This section shall be applicable to this AGREEMENT only if
any of the funds made available to the CONTRACTOR under this AGREEMENT are federal
funds.
a. LOBBYING CERTIFICATION
1) If the CONTRACTOR is a tax-exempt organization under Section 501 (c)(4) of
the Internal Revenue Code, the CONTRACTOR certifies that it will not
engage in lobbying activities of any kind regardless of how funded.
10/08
2) The CONTRACTOR acknowledges that as a recipient of federal appropriated
funds, it is subject to the limitations on the use of such funds to influence
certain Federal contracting and financial transactions, as specified in Public
Law 101-121, section 319, and codified in section 1352 of Title 31 of the
United States Code. In accordance with P.L. 101-121, section 319, 31 U.S.C.
1352 and implementing regulations, the CONTRACTOR affirmatively
acknowledges and represents that it is prohibited and shall refrain from using
Federal funds received under this AGREEMENT for the purposes of lobbying;
provided, however, that such prohibition does not apply in the case of a
payment of reasonable compensation made to an officer or employee of the
CONTRACTOR to the extent that the payment is for agency and legislative
liaison activities not directly related to the awarding of any Federal contract,
the making of any Federal grant or loan, the entering into of any cooperative
agreement, or the extension, continuation, renewal, amendment or
modification of any Federal contract, grant, loan or cooperative agreement.
Nor does such prohibition prohibit any reasonable payment to a person in
connection with, or any payment of reasonable compensation to an officer or
employee of the CONTRACTOR if the payment is for professional or technical
services rendered directly in the preparation, submission or negotiation of any
bid, proposal, or application for a Federal contract, grant, loan, or cooperative
agreement, or an extension, continuation, renewal, amendment, or
modification thereof, or for meeting requirements imposed by or pursuant to
law as a condition for receiving that Federal contract, grant, loan or
cooperative agreement.
3)
This section shall be applicable to this AGREEMENT only if federal funds
allotted exceed $100,000.
a) The CONTRACTOR certifies, to the best of his or her knowledge and belief, that:
♦ No federal appropriated funds have been paid or will be paid, by or
on behalf of the CONTRACTOR, to any person for influencing or
attempting to influence an officer or employee of an agency, a
Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with the
awarding of any federal contract, the making of any federal loan,
the entering into of any cooperative agreement, and the extension,
continuation, renewal amendment or modification of any federal
contract, grant, loan, or cooperative agreement.
♦ If any funds other than federal appropriated funds have been paid
or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of
a Member of Congress in connection with this federal contract,
grant, loan, or cooperative agreement, the CONTRACTOR shall
complete and submit Standard Form-LLL, "Disclosure Form to
Report Lobbying" in accordance with its instructions.
b) The CONTRACTOR shall require that the language of this certification be
included in the award documents for all sub-awards at all tiers (including
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subcontracts, sub-grants, and contracts under grants, loans, and cooperative
agreements) and that all sub-recipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction imposed
by section 1352, title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.
c) The CONTRACTOR shall disclose specified information on any agreement with
lobbyists whom the CONTRACTOR will pay with other Federal appropriated
funds by completion and submission to the STATE of the Federal Standard FormLLL, "Disclosure Form to Report Lobbying", in accordance with its instructions.
This form may be obtained by contacting either the Office of Management and
Budget Fax Information Line at (202) 395-9068 or the Bureau of Accounts
Management at (518) 474-1208. Completed forms should be submitted to the
New York State Department of Health, Bureau of Accounts Management, Empire
State Plaza, Corning Tower Building, Room 1315, Albany, 12237-0016.
d) The CONTRACTOR shall file quarterly updates on the use of lobbyists if material
changes occur, using the same standard disclosure form identified in
(c) above to report such updated information.
4) The reporting requirements enumerated in subsection (3) of this paragraph
shall not apply to the CONTRACTOR with respect to:
a) Payments of reasonable compensation made to its regularly employed
officers or employees;
b) A request for or receipt of a contract (other than a contract referred to in
clause (c) below), grant, cooperative agreement, subcontract (other than
a subcontract referred to in clause (c) below), or subgrant that does not
exceed $100,000; and
c) A request for or receipt of a loan, or a commitment providing for the
United States to insure or guarantee a loan, that does not exceed
$150,000, including a contract or subcontract to carry out any purpose
for which such a loan is made.
b. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE:
Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires
that smoking not be permitted in any portion of any indoor facility owned or leased
or contracted for by an entity and used routinely or regularly for the provision of
health, day care, early childhood development services, education or library
services to children under the age of 18, if the services are funded by federal
programs either directly or through State or local governments, by federal grant,
contract, loan, or loan guarantee. The law also applies to children's services that
are provided in indoor facilities that are constructed, operated, or maintained with
such federal funds. The law does not apply to children's services provided in
private residences; portions of facilities used for inpatient drug or alcohol
10/08
treatment; service providers whose sole source of applicable federal funds is
Medicare or Medicaid; or facilities where WIC coupons are redeemed. Failure to
comply with the provisions of the law may result in the imposition of a monetary
penalty of up to $1000 for each violation and/or the imposition of an
administrative compliance order on the responsible entity.
By signing this AGREEMENT, the CONTRACTOR certifies that it will comply with
the requirements of the Act and will not allow smoking within any portion of any
indoor facility used for the provision of services for children as defined by the Act.
The CONTRACTOR agrees that it will require that the language of this
certification be included in any subawards which contain provisions for children's
services and that all subrecipients shall certify accordingly.
c. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
Regulations of the Department of Health and Human Services, located at Part 76 of Title 45
of the Code of Federal Regulations (CFR), implement Executive Orders 12549 and 12689
concerning debarment and suspension of participants in federal programs and activities.
Executive Order 12549 provides that, to the extent permitted by law, Executive departments
and agencies shall participate in a government-wide system for non-procurement debarment
and suspension. Executive Order 12689 extends the debarment and suspension policy to
procurement activities of the federal government. A person who is debarred or suspended
by a federal agency is excluded from federal financial and non-financial assistance and
benefits under federal programs and activities, both directly (primary covered transaction)
and indirectly (lower tier covered transactions). Debarment or suspension by one federal
agency has government-wide effect.
Pursuant to the above-cited regulations, the New York State Department of Health (as a
participant in a primary covered transaction) may not knowingly do business with a person
who is debarred, suspended, proposed for debarment, or subject to other government-wide
exclusion (including any exclusion from Medicare and State health care program participation
on or after August 25, 1995), and the Department of Health must require its prospective
contractors, as prospective lower tier participants, to provide the certification in Appendix B to
Part 76 of Title 45 CFR, as set forth below:
1) APPENDIX B TO 45 CFR PART 76-CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
EXCLUSION-LOWER TIER COVERED TRANSACTIONS
Instructions for Certification
a) By signing and submitting this proposal, the prospective lower tier
participant is providing the certification set out below.
b) The certification in this clause is a material representation of fact upon
which reliance was placed when this transaction was entered into. If it is
later determined that the prospective lower tier participant knowingly
rendered and erroneous certification, in addition to other remedies available
to the Federal Government the department or agency with which this
transaction originated may pursue available remedies, including suspension
and/or debarment.
c) The prospective lower tier participant shall provide immediate written notice
to the person to which this proposal is submitted if at any time the
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prospective lower tier participant learns that its certification was erroneous
when submitted or had become erroneous by reason of changed
circumstances.
d) The terms covered transaction, debarred, suspended, ineligible, lower tier
covered transaction, participant, person, primary covered transaction,
principal, proposal, and voluntarily excluded, as used in this clause, have
the meaning set out in the Definitions and Coverage sections of rules
implementing Executive Order 12549. You may contact the person to which
this proposal is submitted for assistance in obtaining a copy of those
regulations.
e) The prospective lower tier participant agrees by submitting this proposal
that, should the proposed covered transaction be entered into, it shall not
knowingly enter into any lower tier covered transaction with a person who is
proposed for debarment under 48 CFR part 9, subpart 9.4, debarred,
suspended, declared ineligible, or voluntarily excluded from participation in
this covered transaction, unless authorized by the department or agency
with which this transaction originated.
f) The prospective lower tier participant further agrees by submitting this
proposal that it will include this clause titled “Certification Regarding
Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier
Covered Transaction,” without modification, in all lower tier covered
transactions.
g) A participant in a covered transaction may rely upon a certification of a
prospective participant in a lower tier covered transaction that it is not
proposed for debarment under 48 CFR part 9, subpart 9.4, debarred,
suspended, ineligible, or voluntarily excluded from covered transactions,
unless it knows that the certification is erroneous. A participant may decide
the method and frequency by which it determines the eligibility of its
principals. Each participant may, but is not required to, check the List of
Parties Excluded From Federal Procurement and Non-procurement
Programs.
h) Nothing contained in the foregoing shall be construed to require
establishment of a system of records in order to render in good faith the
certification required by this clause. The knowledge and information of a
participant is not required to exceed that which is normally possessed by a
prudent person in the ordinary course of business dealings.
i) Except for transactions authorized under paragraph "e" of these instructions,
if a participant in a covered transaction knowingly enters into a lower tier
covered transaction with a person who is proposed for debarment under 48
CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily
excluded from participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency with which
this transaction originated may pursue available remedies, including
suspension and/or debarment.
2) Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion –
Lower Tier Covered Transactions
a) The prospective lower tier participant certifies, by submission of this
10/08
proposal, that neither it nor its principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department agency.
b) Where the prospective lower tier participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an
explanation to this proposal.
6. The STATE, its employees, representatives and designees, shall have the right at any time
during normal business hours to inspect the sites where services are performed and observe the
services being performed by the CONTRACTOR. The CONTRACTOR shall render all assistance and
cooperation to the STATE in making such inspections. The surveyors shall have the responsibility for
determining contract compliance as well as the quality of service being rendered.
7. The CONTRACTOR will not discriminate in the terms, conditions and privileges of
employment, against any employee, or against any applicant for employment because of
race, creed, color, sex, national origin, age, disability, sexual orientation or marital status. The
CONTRACTOR has an affirmative duty to take prompt, effective, investigative and remedial action
where it has actual or constructive notice of discrimination in the terms, conditions or privileges of
employment against (including harassment of) any of its employees by any of its other
employees, including managerial personnel, based on any of the factors listed above.
8. The CONTRACTOR shall not discriminate on the basis of race, creed, color, sex, national
origin, age, disability, sexual orientation or marital status against any person seeking services for which
the CONTRACTOR may receive reimbursement or payment under this AGREEMENT.
9. The CONTRACTOR shall comply with all applicable federal, State and local civil rights and
human rights laws with reference to equal employment opportunities and the provision of
services.
10. The STATE may cancel this AGREEMENT at any time by giving the CONTRACTOR not
less than thirty (30) days written notice that on or after a date therein specified, this
AGREEMENT shall be deemed terminated and cancelled.
11. Where the STATE does not provide notice to the NOT-FOR-PROFIT CONTRACTOR of its intent to not
renew this contract by the date by which such notice is required by Section 179-t(1) of the State Finance
Law, then this contract shall be deemed continued until the date that the agency provides the notice
required by Section 179-t, and the expenses incurred during such extension shall be reimbursable under
the terms of this contract.
12. Other Modifications
a. Modifications of this AGREEMENT as specified below may be made within an
existing PERIOD by mutual written agreement of both parties:
♦ Appendix B - Budget line interchanges; Any proposed modification to the contract
which results in a change of greater than 10 percent to any budget category, must
be submitted to OSC for approval;
♦ Appendix C - Section 11, Progress and Final Reports;
♦ Appendix D - Program Workplan will require OSC approval.
b. To make any other modification of this AGREEMENT within an existing PERIOD,
the parties shall revise or complete the appropriate appendix form(s), and a
10/08
Modification Agreement (Appendix X is the blank form to be used), which shall be
effective only upon approval by the Office of the State Comptroller.
13. Unless the CONTRACTOR is a political sub-division of New York State, the CONTRACTOR
shall provide proof, completed by the CONTRACTOR's insurance carrier and/or the
Workers' Compensation Board, of coverage for
Workers' Compensation, for which one of the following is incorporated into this contract as
Appendix E-1:
•
CE-200 - Certificate of Attestation For New York Entities With No Employees And
Certain Out Of State Entities, That New York State Workers' Compensation And/Or
Disability Benefits Insurance Coverage is Not Required; OR
•
C-105.2 -- Certificate of Workers' Compensation Insurance. PLEASE NOTE: The
State Insurance Fund provides its own version of this form, the U-26.3; OR
•
SI-12 -- Certificate of Workers' Compensation Self-Insurance, OR GSI-105.2 -Certificate of Participation in Workers' Compensation Group Self-Insurance
Disability Benefits coverage, for which one of the following is incorporated into this contract as
Appendix E-2:
•
CE-200 - Certificate of Attestation For New York Entities With No Employees And
Certain Out Of State Entities, That New York State Workers' Compensation And/Or
Disability Benefits Insurance Coverage is Not Required; OR
•
DB-120.1 -- Certificate of Disability Benefits Insurance OR
•
DB-155 -- Certificate of Disability Benefits Self-Insurance
14. Contractor shall comply with the provisions of the New York State Information Security Breach and
Notification Act (General Business Law Section 899-aa; State Technology Law Section 208). Contractor
shall be liable for the costs associated with such breach if caused by Contractor's negligent or willful
acts or omissions, or the negligent or willful acts or omissions of Contractor's agents, officers,
employees or subcontractors.
15. All products supplied pursuant to this agreement shall meet local, state and federal regulations,
guidelines and action levels for lead as they exist at the time of the State's acceptance of this contract.
16. Additional clauses as may be required under this AGREEMENT are annexed hereto as
appendices and are made a part hereof if so indicated on the face page of this AGREEMENT.
10/08
APPENDIX B
BUDGET
(sample format)
Organization Name: ___________________________________________________________
Budget Period:
Commencing on: _____________________
Ending on: _____________
Personal Service
Number
Title
% Time
Devoted to
This Project
Annual
Salary
Total Amount
Budgeted From
NYS
Total Salary
Fringe Benefits (specify rate)
TOTAL PERSONAL SERVICE:
____________
____________
____________
Other Than Personal Service
Amount
Category
Supplies
Travel
Telephone
Postage
Photocopy
Other Contractual Services (specify)
Equipment (Defray Cost of Defibrillator)
____________
TOTAL OTHER THAN PERSONAL SERVICE
____________
GRAND TOTAL
____________
Federal funds are being used to support this contract. Code of Federal Domestic
Assistance (CFDA) numbers for these funds are:
(required)
10/08
APPENDIX C
PAYMENT AND REPORTING SCHEDULE
1.
Payment and Reporting Terms and Conditions
A.
The STATE may, at its discretion, make an advance payment to the CONTRACTOR,
during the initial or any subsequent PERIOD, in an amount to be determined by the
STATE but not to exceed ______ percent of the maximum amount indicated in the
budget as set forth in the most recently approved Appendix B. If this payment is to
be made, it will be due thirty calendar days, excluding legal holidays, after the later of
either:
 the first day of the contract term specified in the Initial Contract Period
identified on the face page of the AGREEMENT or if renewed, in the
PERIOD identified in the Appendix X, OR
 if this contract is wholly or partially supported by Federal funds, availability
of the federal funds;
provided, however, that a STATE has not determined otherwise in a written
notification to the CONTRACTOR suspending a Written Directive associated with this
AGREEMENT, and that a proper voucher for such advance has been received in the
STATE’s designated payment office. If no advance payment is to be made, the initial
payment under this AGREEMENT shall be due thirty calendar days, excluding legal
holidays, after the later of either:
 the end of the first monthly/quarterly period of this AGREEMENT; or
 if this contract is wholly or partially supported by federal funds, availability
of the federal funds:
provided, however, that the proper voucher for this payment has been received in the
STATE’s designated payment office.
B.
No payment under this AGREEMENT, other than advances as authorized herein, will
be made by the STATE to the CONTRACTOR unless proof of performance of
required services or accomplishments is provided. If the CONTRACTOR fails to
perform the services required under this AGREEMENT the STATE shall, in addition
to any remedies available by law or equity, recoup payments made but not earned,
by set-off against any other public funds owed to CONTRACTOR.
C.
Any optional advance payment(s) shall be applied by the STATE to future payments
due to the CONTRACTOR for services provided during initial or subsequent
PERIODS. Should funds for subsequent PERIODS not be appropriated or budgeted
by the STATE for the purpose herein specified, the STATE shall, in accordance with
Section 41 of the State Finance Law, have no liability under this AGREEMENT to the
CONTRACTOR, and this AGREEMENT shall be considered terminated and
cancelled.
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D.
The CONTRACTOR will be entitled to receive payments for work, projects, and
services rendered as detailed and described in the program workplan, Appendix D.
All payments shall be in conformance with the rules and regulations of the Office of
the State Comptroller.
E.
The CONTRACTOR will provide the STATE with the reports of progress or other
specific work products pursuant to this AGREEMENT as described in this Appendix
below. In addition, a final report must be submitted by the CONTRACTOR no later
than ____ days after the end of this AGREEMENT. All required reports or other work
products developed under this AGREEMENT must be completed as provided by the
agreed upon work schedule in a manner satisfactory and acceptable to the STATE in
order for the CONTRACTOR to be eligible for payment.
F.
The CONTRACTOR shall submit to the STATE monthly/quarterly voucher claims and
reports of expenditures on such forms and in such detail as the STATE shall require.
The CONTRACTOR shall submit vouchers to the State’s designated payment office
located in the _________________________________________.
All vouchers submitted by the CONTRACTOR pursuant to this AGREEMENT shall
be submitted to the STATE no later than ___________________ days after the end
date of the period for which reimbursement is being claimed. In no event shall the
amount received by the CONTRACTOR exceed the budget amount approved by the
STATE, and, if actual expenditures by the CONTRACTOR are less than such sum,
the amount payable by the STATE to the CONTRACTOR shall not exceed the
amount of actual expenditures.
All contract advances in excess of actual
expenditures will be recouped by the STATE prior to the end of the applicable budget
period.
G.
If the CONTRACTOR is eligible for an annual cost of living adjustment (COLA),
enacted in New York State Law, that is associated with this grant AGREEMENT,
payment of such COLA shall be made separate from payments under this
AGREEMENT and shall not be applied toward or amend amounts payable under
Appendix B of this AGREEMENT.
Before payment of a COLA can be made, the STATE shall notify the CONTRACTOR,
in writing, of eligibility for any COLA. The CONTRACTOR shall be required to submit
a written certification attesting that all COLA funding will be used to promote the
recruitment and retention of staff or respond to other critical non-personal service
costs during the State fiscal year for which the cost of living adjustment was
allocated, or provide any other such certification as may be required in the enacted
legislation authorizing the COLA.
II.
Progress and Final Reports
Organization Name: ______________________________________________________
Report Type:
A.
Narrative/Qualitative Report
___________________________ (Organization Name) will submit, on a quarterly
basis, not later than __________ days from the end of the quarter, a report, in
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narrative form, summarizing the services rendered during the quarter. This report will
detail how the ________________________ (Organization) _________________
has progressed toward attaining the qualitative goals enumerated in the Program
Workplan (Appendix D).
(Note: This report should address all goals and objectives of the project and include
a discussion of problems encountered and steps taken to solve them.)
B.
Statistical/Quantitative Report
___________________________ (Organization Name) will submit, on a quarterly
basis, not later than __________ days from the end of the quarter, a detailed report
analyzing the quantitative aspects of the program plan, as appropriate (e.g., number
of meals served, clients transported, patient/client encounters, procedures
performed, training sessions conducted, etc.)
C.
Expenditure Report
___________________________ (Organization Name) ______________ will
submit, on a quarterly basis, not later than __________ days after the end date for
which reimbursement is being claimed, a detailed expenditure report, by object of
expense. This report will accompany the voucher submitted for such period.
D.
Final Report
___________________________ (Organization Name) _________________ will
submit a final report, as required by the contract, reporting on all aspects of the
program, detailing how the use of grant funds were utilized in achieving the goals set
forth in the program Workplan.
10/08
APPENDIX D
PROGRAM WORKPLAN
(sample format)
A well written, concise workplan is required to ensure that the Department and the contractor are
both clear about what the expectations under the contract are. When a contractor is selected
through an RFP or receives continuing funding based on an application, the proposal submitted by
the contractor may serve as the contract’s work plan if the format is designed appropriately. The
following are suggested elements of an RFP or application designed to ensure that the minimum
necessary information is obtained. Program managers may require additional information if it is
deemed necessary.
I.
CORPORATE INFORMATION
Include the full corporate or business name of the organization as well as the
address, federal employer identification number and the name and telephone number(s) of
the person(s) responsible for the plan’s development. An indication as to whether the
contract is a not-for-profit or governmental organization should also be included. All not-forprofit organizations must include their New York State charity registration number; if the
organization is exempt AN EXPLANATION OF THE EXEMPTION MUST BE ATTACHED.
II.
SUMMARY STATEMENT
This section should include a narrative summary describing the project which will be
funded by the contract. This overview should be concise and to the point. Further details
can be included in the section which addresses specific deliverables.
III.
PROGRAM GOALS
This section should include a listing, in an abbreviated format (i.e., bullets), of the
goals to be accomplished under the contract. Project goals should be as quantifiable as
possible, thereby providing a useful measure with which to judge the contractor’s
performance.
IV.
SPECIFIC DELIVERABLES
A listing of specific services or work projects should be included. Deliverables should
be broken down into discrete items which will be performed or delivered as a unit (i.e., a
report, number of clients served, etc.) Whenever possible a specific date should be
associated with each deliverable, thus making each expected completion date clear to both
parties.
Language contained in Appendix C of the contract states that the contractor is not
eligible for payment “unless proof of performance of required services or accomplishments
is provided.” The workplan as a whole should be structured around this concept to ensure
that the Department does not pay for services that have not been rendered.
10/08
Agency Code 12000
APPENDIX X
Contract Number:__________
Contractor:________________________
Amendment Number X- ______
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through NYS
Department of Health, having its principal office at Albany, New York, (hereinafter referred to as
the STATE), and ___________________________________ (hereinafter referred to as the
CONTRACTOR), for amendment of this contract.
This amendment makes the following changes to the contract (check all that apply):
______ Modifies the contract period at no additional cost
______ Modifies the contract period at additional cost
______ Modifies the budget or payment terms
______ Modifies the work plan or deliverables
______ Replaces appendix(es) _________ with the attached appendix(es)_________
______ Adds the attached appendix(es) ________
______ Other: (describe) ________________________________
This amendment is__ is not__ a contract renewal as allowed for in the existing contract.
All other provisions of said AGREEMENT shall remain in full force and effect.
Prior to this amendment, the contract value and period were:
$
From
(Value before amendment)
/
/
to
/
/
.
(Initial start date)
This amendment provides the following addition (complete only items being modified):
$
From
/
/
to
/
/
to
/
/
.
/
/
.
This will result in new contract terms of:
$
(All years thus far combined)
From
(Initial start date)
Page 19 of 20
Ver. 12/13/07
10/08
(Amendment end date)
Signature Page for:
Contract Number:__________
Contractor:_________________________
Amendment Number: X-_____
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates
appearing under their signatures.
CONTRACTOR SIGNATURE:
By:
Date: _________________________
(signature)
Printed Name:
Title:
_______________
STATE OF NEW YORK
County of
)
)
)
SS:
day of
in the year ______ before me, the undersigned, personally appeared
On the
___________________________________, personally known to me or proved to me on the basis of satisfactory
evidence to be the individual(s) whose name(s) is(are) subscribed to the within instrument and acknowledged to me
that he/she/they executed the same in his/her/their/ capacity(ies), and that by his/her/their signature(s) on the
instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
____________________________________________________
(Signature and office of the individual taking acknowledgement)
_____________________________________________________
STATE AGENCY SIGNATURE
"In addition to the acceptance of this contract, I also certify that original copies of this signature
page will be attached to all other exact copies of this contract."
Date:
By:
(signature)
Printed Name:
Title:
______________
_______________________________________________
ATTORNEY GENERAL'S SIGNATURE
By:
Date:
STATE COMPTROLLER'S SIGNATURE
By:
Date:
Page 20 of 20
Ver. 12/13/07
10/08
Attachment 2
Letter of Interest Form
Insert of Agency Letterhead
Cheryl L. Veith
Bureau of Women’s Health
New York State Department of Health
Empire State Plaza
Corning Tower, Room 1805
Albany, NY 12237-0657
Re:
FAU#
Initiative to Increase Awareness of the Availability of Emergency Contraception in
New York State
Dear Ms. Veith:
This letter is to request that our organization be registered for the applicant’s conference
to be held on August 19, 2009 via teleconference; to receive written responses to the
questions; and to receive any updates or modifications to this RFA.
We understand that in order to register for the bidder’s conference and to receive any
RFA updates/modification and answers to written questions, The Department of Health
requests this letter be received in the Bureau of Women’s Health by 5:00 p.m. on
August 5, 2009.
Sincerely,
__________________________
Print name
__________________________
Title and Agency
__________________________
E-mail address
39
Attachment 3
Initiative to Increase Awareness of the Availability of
Emergency Contraception (EC) in New York State
Application Checklist
The following completed documents are to be submitted with your RFA
application for the period of 1/1/10 through 12/31/10. This list provides the order
the required documents must be submitted, and serves as your application
checklist. Please ensure that all required forms are submitted.
_________ Application Cover Sheet (Attachment 4)
_________ Statement of Assurances (Attachment 5)
_________ Project Narrative
_________ Workplan (Attachment 6)
_________ Budget Narrative/Justification (Attachment 7)
_________ Budget Forms (Attachment 8)
_________ Vendor Responsibility Attestation (Attachment 9)
_________ Vendor Responsibility Questionnaire (Attachment 10)
40
Attachment 4
Application Coversheet
1. TITLE OF PROJECT (PROGRAM):
2. REGION TO BE SERVED:
3. NAME AND ADDRESS OF APPLICANT AGENCY:
Congressional District:
4. EMPLOYER'S IDENTIFICATION NUMBER:
(Fed E.I.N.)
5. NYS CHARITY REGISTRATION NUMBER:
Internet Address:
7. BUDGET PERIOD:
January 1, 2010 – December 31, 2010
8. AMOUNT REQUESTED FOR BUDGET PERIOD
(Direct Costs Only)
6. DIRECTOR OF PROJECT
9. FINANCIAL MANAGEMENT OFFICIAL
(Program or Center Director, Coordinator or Principal
Investigator)
NAME:
NAME:
TITLE:
TITLE:
OFFICE TELEPHONE (include area code and extension):
OFFICE TELEPHONE (include area code and extension):
OFFICE FAX NUMBER:
OFFICE FAX NUMBER:
E-Mail Address:
E-Mail Address:
NAME OF OFFICAL:
SIGNATURE OF OFFICAL:
41
Attachment 5
Statement of Assurances
To be signed by the chief official of the applicant organization:
 Funds awarded will be used only to support a public awareness campaign
regarding the use and availability of Emergency Contraception as described in
the application and as appear on an approved workplan.
 All expenditures and revenues will be maintained through a general accounting
system to allow for identification.
 Data will be kept as requested by the Bureau of Women’s Health. Four quarterly
reports, an annual project report, an annual inventory and quarterly expenditure
reports will be submitted to the New York State Department of Health.
 The applicant will allow the New York State Department of Health access to
conduct site visits as necessary throughout the grant period.
 Contractor will possess, at no cost to the State, all qualifications, licenses and
permits to engage in the required business as may be required within the
jurisdiction where the work specified is to be performed. Workers to be employed
in the performance of this contract will possess the qualifications, training,
licenses and permits as may be required within such jurisdiction.
 The signature below indicates that the applicant accepts the terms and
conditions in the Request for Applications.
I have express authority to make these assurances on behalf of the applicant.
Signature: ___________________________________ Date: ___________
Please PRINT name and title: ____________________________________
Organization Name: ____________________________________________
42
Attachment 6
Work Plan Format
Applicant:
RFA FAU#:0904090336
Initiative to Increase Awareness of Emergency Contraception
Workplan
January 1, 2010 – December 31, 2010
Objectives
Specific
Activities
Time
Frame
Person
Responsible
Evaluation
Measures
43
Attachment 7
Emergency Contraception Education and Outreach Program
Budget Instructions
Prepare an annualized budget for the 12-month period starting January 1, 2010 and
ending December 31, 2010, using the attached forms and instructions. If there are
anticipated delays in hiring, you will need to include the annualized salary and pro-rate it
based on the number of months actually employed. There will be no roll-over of funds
from one year to the next.
A description and justification of each personnel line item and non-personal services
budget line should be provided. Identify key staff for the project by name, title and their
proposed responsibilities. Staffing is expected to be consistent with the level of effort
described in the work plan. Each position should be fully justified, and the appropriate
qualifications required for the position should be stated.
The salaries that are included in the budget need to be actual annual salaries and not
some composite based on potential raises. Increments for salaries will only be given
(within budget constraints) if there is an actual formal agreement that a raise has been
approved and will take effect on a specific date. In that event, two salary lines will be
required for the individual scheduled for a raise, one for each salary level and the
number of months of the budget. Retroactive salary increases are not allowed. Vacant
positions should be reported as an attachment to the quarterly voucher and the
progress reports. The explanation needs to include what has been done to recruit and
fill the positions and describe any problems with filling the vacancy(ies).
Administrative costs should be appropriate to the operation of the program and kept to a
maximum of 10% of the amount being requested from New York State in your
application. Each administrative cost should have a separate line item in the budget.
The budget may allow for reasonable costs for the required annual independent audit, if
an audit is required by state and federal requirements. Audit and other shared costs
should be allocated to the Emergency Contraception Outreach and Education Program
based on a defined agency allocation methodology. Indirect costs applied as a
percentage are not allowed.
An example of shared cost is when personnel function across more than one funded
program. Hence the total cost of their being on the payroll is a “shared cost.” Other
examples might include but are not limited to space-related costs, communications,
office supplies, photocopy, legal, insurance, payroll services and accounting. Identify
44
each such cost that appears in your budget. Provide a written and quantified
explanation of the allocation of each shared cost item in the budget across agency
funding sources (demonstrating the percentage and amount for each of the agency’s
programs).
OPERATING BUDGET FUNDING REQUEST TABLES
Table A: Summary Budget Request
This Table should be completed last and will include the total lines only from Table A-1
(Personal Services) and Table A-2 (Non-personal Services) and the Grand Total. As a
check, grand total requested from DOH should match your funding request. Total
expense = DOH + Other Sources. Other sources may be in-kind, other grants, etc.
Table A-1: Personal Service
Personnel contributing any part of their time to the project should be listed with the
following items completely filled in:
Title: The title given should reflect either a position within your organization or on this
project. List names, titles and positions. Indicate whether the position is full-time (FT)
or part-time (PT).
Annual Salary: Salaries that are included in the budget need to be actual annual salary
rates for the full time position, and not some composite based on potential raises.
Increments for salaries will only be given (within budget constraints) if there is an actual
formal agreement that a raise has been approved and will take effect on a specific date.
Retroactive salary increases are not allowed. Planned increases need to be requested
and approved, in advance of instituting any changes, by the budget modification
process. If a negotiated increase will go into effect, the position should be indicated on
2 separate lines, with the projected number of months at each salary (see example
below.)
% FTE: The proportion of time spent on the project based on a full time equivalent
(FTE) should be indicated. One FTE is based on the number of hours worked in oneweek by salaried employees (e.g., 40 hour work week). To obtain % FTE, divide the
hours per week spent on the project by the number of hours in a work week. For
example, an individual working 10 hours per week on the project given a 40 hour work
week = 10/40 = .25 FTE (shown in decimal form) or 25% (shown as a percentage).
# of Months: Show the number of months out of 12 worked for each title.
Total Expense: Total expense can be calculated using the following method:
45
Total Annual Salary x % FTE x (months worked /12) = Total Expense
Total Expense needs to be distributed between (1) Amount Requested from NYS and
(2) Other Source, as deemed appropriate by your fiscal staff. You may use any
combination of these two categories for each line item, as long as the combined total
amount is equal to the total expense for each line item. This is also applicable to Table
A-2.
Note: If the employee is part-time, mark “PT” after the title, include the annual salary
rate for a full time employee, the % FTE for the part time employee in the position, the
number of months the employee is in the position and the actual salary amount charged
to the grant.
For example:
Title
Annual
Salary
%FTE
# Months
Total
Expense
Secretary PT
$24,000
50%
12
$ 12,000
In a case in which the salary of an employee will change during the contract year
regardless of the amount of time spent on this project, the total annual salary for each
position should be given for the number of months applicable to that salary.
For example, if a union negotiated contract salary increase will impact a portion of the
12-month budget period it should be shown on Table A-1 as follows (the same position
will use two lines in the budget):
Title
Annual
Salary
Secretary FT $22,500
Secretary FT $24,000
%FTE
# Months
Total
Expense
100%
100%
8
4
$15,000
$ 8,000
Fringe Benefits: Insert the calculated Fringe rate (from Form B-2) in the space
provided. Multiply this rate by the sub-total of Personal Services (Amount in Total
Expense column subtotal Personal line). The total fringe amount should be shown (total
expense x fringe rate from Form B-2).
TABLE A-2: NON-PERSONAL SERVICES (OTPS)
46
ALL non-personal service expenses that are directly related to the conduct of program
activities should be listed regardless of whether or not funding for these expenses is
requested from New York State. As with Table A-1, distribute the total expense
between DOH and Other Sources (specify other sources). See instructions for Form B3 for allowable non-personal costs.
BUDGET NARRATIVE/JUSTIFICATION FORMS:
Use Forms B-1 and B-3 to provide a justification/explanation for the expenses included in the
Operating Budget and Funding Request Tables. The justification needs to show all items of
expense and the associated costs that comprise the amount requested for each budget
category (e.g., if your total travel cost is $1,000, show how that amount was determined –
provide details of expenses for conferences, local travel, etc.), and an explanation of how
these expenses relate to the goals and objectives of the project.
FORM B-1: PERSONAL SERVICES
List each title, the name of the incumbent, and a description for each position, including the
percentage of time spent on various duties where appropriate, on this form. Contracted or per
diem staff are not to be included in personal services; these expenses should be shown as
consultant or contractual services under non-personal services. Specifically describe the
methodology used when salaries are allocated across multiple programs within the agency.
For all positions please provide the total number of hours worked weekly for the agency as well
as the number of hours worked on this program.
FORM B-2: FRINGE BENEFIT RATE
Specify the components (FICA, Health Insurance and Life Insurance, Unemployment
Insurance, Retirement, Workmen’s Compensation and Disability Insurance) and their
percentages comprising the fringe benefit rate, then total the percentages to show the
fringe benefit rate used in budget calculations. Form B-2 already lists the standard
components of a fringe benefit rate. If different rates are used for different positions,
submit Form B-2 for each rate (make copies of Form B-2, if necessary) and specify
which positions are subject to that rate.
Compute an average of the multiple fringe rates for your personnel. Use an average of
the multiple fringe benefit rates on Table A-1.
FORM B-3: NON-PERSONAL SERVICES
Include all program services and administrative costs that are directly related to the
conduct of program activities. Itemize in detail equipment and supplies by type and
47
cost. Contractual services should also be itemized. This includes utilities, advertising,
postage, photocopying, etc. Specifically describe the methodology for allocation of
shared costs.
Overhead
Overhead is not allowable as a single line item. If you are seeking reimbursement for
those administrative costs often considered in overhead lines, they need to be broken
out and listed individually as line items. Specifically describe the methodology for
allocation of these costs.
The following is a list of allowable costs that might be indirect or overhead:
Accounting
Audit Service
Bonding
Budgeting
Communication
Personal Service & Appropriate fringe (if supported by time and distribution records)
Personnel Administration
Payroll Preparation
Maintenance & Repair
Central Stores
Motor Pools
Legal services which are approvable under the contract
You may request reimbursement for up to ten percent administrative/indirect costs
equal to the actual expense or a prorated amount based on a methodology that
appropriately allocates the cost across all program components. All indirect costs need
to be lined out separately.
Costs Not Allowed
New construction
Purchase of land or buildings
Renovation that constitutes new construction
Depreciation
Entertainment
Bad debts
Individual Professional dues
Honoraria (speaker’s fee is acceptable)
Fund Raising
Interest Costs
Alcoholic Beverages
Lobbying
Contingency funds
48
Fines, Penalties
Pre-award Costs
Overhead, Indirect or Administration costs (not lined out)
Legal costs incurred as a result of disputes with DOH
Miscellaneous (if it exceeds $1,000 and, if previous justification has not been approved)
Supplies and Materials
Provide a delineation of the items of expense and estimated cost of each along with
justification of their need. Some routine supplies may be consolidated under office
supplies. List educational materials for consumers and providers separately.
Travel
Provide a delineation of the items of expense and estimated cost (i.e., travel costs
associated with conferences, including transportation, meals, lodging, registration fees,
administrative travel vs. programmatic travel, staff travel) and estimated cost along with
a justification of need. The derivation of travel costs should be explained, for example:
travel via auto of 1000 miles @ $0.375/mile = $375, plus per diem rates of $75 for 2
days of travel for 3 staff = $450. Costs should be based upon a travel reimbursement
policy. Travel reimbursement cannot exceed DOH staff travel reimbursement
guidelines, which are available upon request.
The project will be reimbursed for local travel costs not to exceed the current mileage
allowances established by your agency for personal automobile use and also limited to
the IRS mileage rate. The most cost effective method of travel needs to always be
used. Travel costs are limited to those allowed by the project’s travel policy.
Programs are required to obtain prior approval in writing from the Contract Manager in
the Bureau of Women’s Health for Out-of-State conference travel and related expenses.
Per Diem or subsistence allowance need to be reasonable and need to be limited to the
days at the conference plus actual travel time required reaching the conference location
by the most direct route. In the case of air travel, less than first-class needs to be used,
and will be the basis for reimbursement.
Consultants/Per Diems/Contractual Services
This category should be used to budget for time-limited/specific services, which cannot
be accomplished by existing staff, as well as for any services/expenses that will be
provided by a subcontractor. Provide a justification of why each service listed is
needed. Justification should include the name of the consultant/contractor; the specific
service to be provided, the time frame for the delivery of services, costs per hour/day
and total estimated hours/days. In addition, a line time budget for each
49
subcontract/consultant needs to be attached to the form. Any subcontract must be
submitted to the Department for prior approval.
Equipment
An item is defined as equipment if it is an article of tangible personal property having a
useful life of more than two years and an acquisition cost of $300 or more per unit.
These items must be inventoried (tagged) and reported on the annual inventory form.
The tag number, manufacturer serial number, date of purchase, date of disposition,
location, and cost of each item must be reported on an annual inventory form.
Audit
The amount shown for the audit must not exceed 1% of the total funds requested from
New York State Department of Health, unless otherwise negotiated with the BWH
Contract Manager.
Space
Costs of space rental must include the number of square feet, cost per square foot and
the methodology used if the cost is allocated across programs. Detail of maintenance
costs and utilities should be included.
Other
All other non-personal service expenses should be lined out alphabetically and separately and
contain significant detail and an explanation of how these expenses relate to the goals and
objectives of the project.
50
COST ALLOCATION METHODOLOGY
You need to specifically describe the methodology for allocation of shared costs.
Explain and demonstrate how each of the shared costs in your budget is allocated
across funding sources. An example of shared cost is when personnel function across
more than one funded program. Hence the total cost of their being on the payroll is a
“shared cost.” Other examples might include but are not limited to space-related costs,
communications, office supplies, photocopy, legal, insurance, payroll services and
accounting. Identify each such cost that appears in your budget. Provide a justification
of the allocation of each shared cost item in the budget across agency funding sources
(demonstrating the percentage and amount for each of the agency’s programs).
Simple Allocation Methodology
The agency takes the sum of all its contracts, figures out what percent the grant is and
allocates all costs accordingly. For example, if the agency takes in $1 million, and our
grant is $250,000, then the agency allocates 25% of all shared costs to our grant.
Multiple Allocation Methodology
The agency may choose to use multiple allocation methodologies based on cost
centers, by grouping costs then allocating them accordingly. For example,
•
All costs associated with operation, such as printing, copying, mailing, and
telephone, may be grouped and allocated according to use by each grant. The
agency must have a good understanding of the use of these items across all grants
in order to do this. As an alternative, the agency may decide to simply allocate a
percent of these costs to all grants.
•
The agency might also allocate administrative items such as accounting and billing,
etc. If the agency has a grant that has substantial billing, vouchering, and
subcontracting activity, they may allocate more of those costs to that grant.
•
Space might be allocated by taking the cost per square foot and multiplying that by
the number of employees on the grant.
Direct Allocation Methodology
The agency may also consider every expense as a direct cost and allocate it based on
the specific use by each grant.
51
Applicant
Attachment 8
EMERGENCY CONTRACEPTION OUTREACH AND EDUCATION PROGRAM
TABLE A - SUMMARY BUDGET
OPERATING BUDGET AND FUNDING REQUEST
January 1, 2010 - December 31, 2010
Total
Expense
Amount Requested
From NYS
Other Source /
3rd Party
Specify
Other Source
Personal Services
(Total line only from Table A-1)
Nonpersonal Services
(Total line only from Table A-2)
GRAND TOTAL
$0
$0
$0
52
Applicant:
EMERGENCY CONTRACEPTION OUTREACH AND EDUCATION PROGRAM
TABLE A-1 PERSONAL SERVICES
OPERATING BUDGET AND FUNDING REQUEST
January 1, 2010 - December 31, 2010
PERSONAL SERVICES
Title
Annual
Salary
%
FTE
# of
Mos.
Total
Expense
Amount Requested
from NYS
Other Source
Specify
Other Source
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Fringe Benefits*%
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Personal Services
$0
$0
$0
(List Personnel Budgeted)
Subtotal Personal Services
* If more than one fringe benefit is used, use an average fringe rate for the calculation on this form.
Page ____ of ____
Any vacant positions should be reported as an attachment to the quarterly voucher and the progress reports. The explanation
must include what has been done to recruit and fill the positions and describe any problems with filling vacancy (ies).
53
Applicant:
EMERGENCY CONTRACEPTION OUTREACH AND EDUCATION PROGRAM
TABLE A-2 NONPERSONAL SERVICES
OPERATING BUDGET AND FUNDING REQUEST
January 1, 2010 - December 31, 2010
NONPERSONAL SERVICES
Total
Expense
Amount Requested
From NYS
Other Source
Specify Other Source
(List Budgeted Expenses)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Nonpersonal Services
$0
$0
$0
Page _____ of ______
54
BUDGET NARRATIVE/JUSTIFICATION ATTACHMENT
EMERGENCY CONTRACEPTION OUTREACH AND EDUCATION PROGRAM
FORM B-1
PERSONAL SERVICES
January 1, 2010 - December 31, 2010
Applicant:
PERSONAL SERVICES
Title
Incumbent
Description
Page ____ of ____
55
BUDGET NARRATIVE/JUSTIFICATION ATTACHMENT
EMERGENCY CONTRACEPTION OUTREACH AND EDUCATION
FORM B-2
FRINGE BENEFITS
January 1, 2010 - December 31, 2010
Applicant:
FRINGE BENEFITS
Component
FICA
Rate
Unemployment Insurance
Health Insurance
Retirement Benefits
Worker’s Compensation Insurance
Disability Insurance
TOTAL FRINGE BENEFIT RATE*
0.00%
*This amount must equal the percentage used in budget calculations unless
positions have different fringe rates. If this is the case, use an average fringe
benefit rate.
Page ___ of ___
56
BUDGET NARRATIVE/JUSTIFICATION ATTACHMENT
EMERGENCY CONTRACEPTION OUTREACH AND EDUCATION PROGRAM
FORM B-3
NONPERSONAL SERVICES
January 1, 2010 - December 31, 2010
Applicant:
NONPERSONAL SERVICES
Item
Cost
Description
Page ____ of ____
57
Attachment 9
Vendor Responsibility Attestation
To comply with the Vendor Responsibility Requirements outlined in Section IV,
Administrative Requirements, H. Vendor Responsibility Questionnaire, I hereby certify:
Choose one:
An on-line Vender Responsibility Questionnaire has been updated or created at
OSC's website: https://portal.osc.state.ny.us within the last six months.
A hard copy Vendor Responsibility Questionnaire is included with this
application and is dated within the last six months.
A Vendor Responsibility Questionnaire is not required due to an exempt status.
Exemptions include governmental entities, public authorities, public colleges
and universities, public benefit corporations, and Indian Nations.
Signature of Organization Official:
Print/type Name:
Title:
Organization:
Date Signed:
58
STATE OF NEW YORK
VENDOR RESPONSIBILITY QUESTIONNAIRE
FEIN #
1. VENDOR IS:
PRIME CONTRACTOR
SUB-CONTRACTOR
2. VENDOR’S LEGAL BUSINESS NAME
3. IDENTIFICATION NUMBERS
a) FEIN #
4. D/B/A – Doing Business As (if applicable) & COUNTY FILED:
b) DUNS #
5. WEBSITE ADDRESS (if applicable)
6. ADDRESS OF PRIMARY PLACE OF BUSINESS/EXECUTIVE OFFICE
7. TELEPHONE NUMBER
8. FAX NUMBER
9. ADDRESS OF PRIMARY PLACE OF BUSINESS/EXECUTIVE OFFICE
IN NEW YORK STATE, if different from above
10. TELEPHONE NUMBER
11. FAX NUMBER
12. PRIMARY PLACE OF BUSINESS IN NEW YORK STATE IS:
13. AUTHORIZED CONTACT FOR THIS
QUESTIONNAIRE
Owned
Rented
If rented, please provide landlord’s name, address, and telephone number below:
Name
Title
Telephone Number
Fax Number
e-mail
14. VENDOR’S BUSINESS ENTITY IS (please check appropriate box and provide additional information):
a)
Business Corporation
Date of Incorporation
b)
Sole Proprietor
Date Established
c)
General Partnership
Date Established
d)
Not-for-Profit Corporation
Date of Incorporation
e)
Limited Liability Company (LLC)
Date Established
f)
Limited Liability Partnership
Date Established
g)
Other – Specify:
Date Established
State of Incorporation*
State of Incorporation*
Charities Registration Number
Jurisdiction Filed (if applicable)
* If not incorporated in New York State, please provide a copy of authorization to do business in New York.
15. PRIMARY BUSINESS ACTIVITY - (Please identify the primary business categories, products or services provided by your business)
16. NAME OF WORKERS’ COMPENSATION INSURANCE CARRIER:
17. LIST ALL OF THE VENDOR’S PRINCIPAL OWNERS AND THE THREE OFFICERS WHO DIRECT THE DAILY
OPERATIONS OF THE VENDOR (Attach additional pages if necessary):
a) NAME (print)
b) NAME (print)
TITLE
TITLE
c) NAME (print)
Issued: November 1, 2004
d) NAME (print)
TITLE
Page 1 of 6
TITLE
STATE OF NEW YORK
VENDOR RESPONSIBILITY QUESTIONNAIRE
FEIN #
A DETAILED EXPLANATION IS REQUIRED FOR EACH QUESTION ANSWERED WITH A
“YES,” AND MUST BE PROVIDED AS AN ATTACHMENT TO THE COMPLETED
QUESTIONNAIRE. YOU MUST PROVIDE ADEQUATE DETAILS OR DOCUMENTS TO
AID THE CONTRACTING AGENCY IN MAKING A DETERMINATION OF VENDOR
RESPONSIBILITY. PLEASE NUMBER EACH RESPONSE TO MATCH THE QUESTION
NUMBER.
18. Is the vendor certified in New York State as a (check please):
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Minority Business Enterprise (MBE)
Women’s Business Enterprise (WBE)
Disadvantaged Business Enterprise (DBE)?
Please provide a copy of any of the above certifications that apply.
19. Does the vendor use, or has it used in the past ten (10) years, any other
Business Name, FEIN, or D/B/A other than those listed in items 2-4 above?
List all other business name(s), Federal Employer Identification Number(s) or any
D/B/A names and the dates that these names or numbers were/are in use. Explain
the relationship to the vendor.
20. Are there any individuals now serving in a managerial or consulting capacity to
the vendor, including principal owners and officers, who now serve or in the
past three (3) years have served as:
a) An elected or appointed public official or officer?
List each individual’s name, business title, the name of the organization and
position elected or appointed to, and dates of service.
b) A full or part-time employee in a New York State agency or as a consultant,
in their individual capacity, to any New York State agency?
List each individual’s name, business title or consulting capacity and the New
York State agency name, and employment position with applicable service dates.
c) If yes to item #20b, did this individual perform services related to the
solicitation, negotiation, operation and/or administration of public contracts
for the contracting agency?
List each individual’s name, business title or consulting capacity and the New
York State agency name, and consulting/advisory position with applicable
service dates. List each contract name and assigned NYS number.
d) An officer of any political party organization in New York State, whether
paid or unpaid?
List each individual’s name, business title or consulting capacity and the official
political party position held with applicable service dates.
Issued: November 1, 2004
Page 2 of 6
STATE OF NEW YORK
VENDOR RESPONSIBILITY QUESTIONNAIRE
FEIN #
21. Within the past five (5) years, has the vendor, any individuals serving in
managerial or consulting capacity, principal owners, officers, major
stockholder(s) (10% or more of the voting shares for publicly traded
companies, 25% or more of the shares for all other companies), affiliate1 or any
person involved in the bidding or contracting process:
a) 1. been suspended, debarred or terminated by a local, state or federal
authority in connection with a contract or contracting process;
2. been disqualified for cause as a bidder on any permit, license,
concession franchise or lease;
3. entered into an agreement to a voluntary exclusion from
bidding/contracting;
4. had a bid rejected on a New York State contract for failure to comply
with the MacBride Fair Employment Principles;
5. had a low bid rejected on a local, state or federal contract for failure to
meet statutory affirmative action or M/WBE requirements on a
previously held contract;
6. had status as a Women’s Business Enterprise, Minority Business
Enterprise or Disadvantaged Business Enterprise denied, de-certified,
revoked or forfeited;
7. been subject to an administrative proceeding or civil action seeking
specific performance or restitution in connection with any local, state or
federal government contract;
8. been denied an award of a local, state or federal government contract,
had a contract suspended or had a contract terminated for nonresponsibility; or
9. had a local, state or federal government contract suspended or
terminated for cause prior to the completion of the term of the contract?
b) been indicted, convicted, received a judgment against them or a grant of
immunity for any business-related conduct constituting a crime under local,
state or federal law including but not limited to, fraud, extortion, bribery,
racketeering, price-fixing, bid collusion or any crime related to truthfulness
and/or business conduct?
c) been issued a citation, notice, violation order, or are pending an
administrative hearing or proceeding or determination for violations of:
1. federal, state or local health laws, rules or regulations, including but not
limited to Occupational Safety & Health Administration (OSHA) or
New York State labor law;
2. state or federal environmental laws;
3. unemployment insurance or workers’ compensation coverage or claim
requirements;
4. Employee Retirement Income Security Act (ERISA);
5. federal, state or local human rights laws;
6. civil rights laws;
7. federal or state security laws;
Issued: November 1, 2004
Page 3 of 6
Yes
No
Yes
No
Yes
No
STATE OF NEW YORK
VENDOR RESPONSIBILITY QUESTIONNAIRE
FEIN #
8. federal Immigration and Naturalization Services (INS) and Alienage
laws;
9. state or federal anti-trust laws; or
10. charity or consumer laws?
For any of the above, detail the situation(s), the date(s), the name(s), title(s),
address(es) of any individuals involved and, if applicable, any contracting agency,
specific details related to the situation(s) and any corrective action(s) taken by the
vendor.
22. In the past three (3) years, has the vendor or its affiliates1 had any claims,
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
judgments, injunctions, liens, fines or penalties secured by any governmental
agency?
Indicate if this is applicable to the submitting vendor or affiliate. State whether the
situation(s) was a claim, judgment, injunction, lien or other with an explanation.
Provide the name(s) and address(es) of the agency, the amount of the original
obligation and outstanding balance. If any of these items are open, unsatisfied,
indicate the status of each item as “open” or “unsatisfied.”
23. Has the vendor (for profit and not-for profit corporations) or its affiliates1, in
the past three (3) years, had any governmental audits that revealed material
weaknesses in its system of internal controls, compliance with contractual
agreements and/or laws and regulations or any material disallowances?
Indicate if this is applicable to the submitting vendor or affiliate. Detail the type of
material weakness found or the situation(s) that gave rise to the disallowance, any
corrective action taken by the vendor and the name of the auditing agency.
24. Is the vendor exempt from income taxes under the Internal Revenue Code?
Indicate the reason for the exemption and provide a copy of any supporting
information.
25. During the past three (3) years, has the vendor failed to:
a) file returns or pay any applicable federal, state or city taxes?
Identify the taxing jurisdiction, type of tax, liability year(s), and tax liability
amount the vendor failed to file/pay and the current status of the liability.
b) file returns or pay New York State unemployment insurance?
Indicate the years the vendor failed to file/pay the insurance and the current
status of the liability.
26. Have any bankruptcy proceedings been initiated by or against the vendor or its
1
affiliates within the past seven (7) years (whether or not closed) or is any
bankruptcy proceeding pending by or against the vendor or its affiliates
regardless of the date of filing?
Indicate if this is applicable to the submitting vendor or affiliate. If it is an affiliate,
include the affiliate’s name and FEIN. Provide the court name, address and docket
number. Indicate if the proceedings have been initiated, remain pending or have
been closed. If closed, provide the date closed.
Issued: November 1, 2004
Page 4 of 6
STATE OF NEW YORK
VENDOR RESPONSIBILITY QUESTIONNAIRE
FEIN #
27. Is the vendor currently insolvent, or does vendor currently have reason to
Yes
No
Yes
No
Yes
No
believe that an involuntary bankruptcy proceeding may be brought against it?
Provide financial information to support the vendor’s current position, for example,
Current Ratio, Debt Ratio, Age of Accounts Payable, Cash Flow and any documents
that will provide the agency with an understanding of the vendor’s situation.
28. Has the vendor been a contractor or subcontractor on any contract with any
New York State agency in the past five (5) years?
List the agency name, address, and contract effective dates. Also provide state
contract identification number, if known.
29. In the past five (5) years, has the vendor or any affiliates1:
a) defaulted or been terminated on, or had its surety called upon to complete,
any contract (public or private) awarded;
b) received an overall unsatisfactory performance assessment from any
government agency on any contract; or
c) had any liens or claims over $25,000 filed against the firm which remain
undischarged or were unsatisfied for more than 90 days ?
Indicate if this is applicable to the submitting vendor or affiliate. Detail the
situation(s) that gave rise to the negative action, any corrective action taken by the
vendor and the name of the contracting agency.
1
"Affiliate" meaning: (a) any entity in which the vendor owns more than 50% of the voting stock; (b) any
individual, entity or group of principal owners or officers who own more than 50% of the voting stock of
the vendor; or (c) any entity whose voting stock is more than 50% owned by the same individual, entity
or group described in clause (b). In addition, if a vendor owns less than 50% of the voting stock of
another entity, but directs or has the right to direct such entity's daily operations, that entity will be an
"affiliate" for purposes of this questionnaire.
Issued: November 1, 2004
Page 5 of 6
STATE OF NEW YORK
VENDOR RESPONSIBILITY QUESTIONNAIRE
FEIN #
State of:
)
County of:
) ss:
)
CERTIFICATION:
The undersigned: recognizes that this questionnaire is submitted for the express purpose of
assisting the State of New York or its agencies or political subdivisions in making a
determination regarding an award of contract or approval of a subcontract; acknowledges that the
State or its agencies and political subdivisions may in its discretion, by means which it may
choose, verify the truth and accuracy of all statements made herein; acknowledges that
intentional submission of false or misleading information may constitute a felony under Penal
Law Section 210.40 or a misdemeanor under Penal Law Section 210.35 or Section 210.45, and
may also be punishable by a fine and/or imprisonment of up to five years under 18 USC Section
1001 and may result in contract termination; and states that the information submitted in this
questionnaire and any attached pages is true, accurate and complete.
The undersigned certifies that he/she:
 has not altered the content of the questions in the questionnaire in any manner;
 has read and understands all of the items contained in the questionnaire and any pages
attached by the submitting vendor;
 has supplied full and complete responses to each item therein to the best of his/her
knowledge, information and belief;
 is knowledgeable about the submitting vendor’s business and operations;
 understands that New York State will rely on the information supplied in this questionnaire
when entering into a contract with the vendor; and
 is under duty to notify the procuring State Agency of any material changes to the vendor’s
responses herein prior to the State Comptroller’s approval of the contract.
Name of Business
Signature of Owner/Officer_________________
Address
Printed Name of Signatory
City, State, Zip
Title
Sworn to before me this ________ day of ______________________________, 20____;
_______________________________________
Notary Public
______________________________________________________
Print Name
______________________________________________________
Signature
______________________________________________________
Date
Issued: November 1, 2004
Page 6 of 6